Transition to Professional Practice

Introduction to Post-Op Case of Hip Replacement

The patient in the given case study is an 80-year-old female who is admitted in the clinical setting for post-operative management after getting right total posterior hip replacement. The patient is residing in her home along with her husband who is 83-years-old. She takes care of herself on her own as well as of her husband. The patient resides in an area which is 65 km away from the city. She is having her daughter who lives nearby and helps her with her daily chores and managing her health. The patient is suffering from multiple ailments, for which she is on medication management. The patient is a known case of osteoarthritis and hypocholesterolaemia since 2001. She is having a surgical history of left total knee replacement in 2017 and right total knee replacement in 2009. Apart from other conditions, patient is also suffering from hypertension, type-2 diabetes and hypothyroidism since 1980. She is having no personal history of smoking; however, she drinks occasionally. The patient is currently suffering from chronic pain in her right hip for which she had been advised to get surgical intervention. The patient case will be pondered upon from the point of view of post-operative management and the nursing care and coordination which will be required to help the patient in recovering from the same. The case will also help in highlighting the concept of defining short-term and long-term goals for the patient, to formulate the basis of treatment. The case will also guide about the discharge planning for this patient, with the help of multidisciplinary approach.

Pathophysiology of Chronic Pain in Elderlies

The transition of degenerative changes has been significantly found to be directly associated with aging process in population (Briggs, 2019). This has been caused to find an increased prevalence of problems in elderlies. Musculoskeletal disorders such as degenerative joints as well as arthritic conditions have been defined as the most common cause of chronic pain in elderlies. Some of the other significant conditions include, pain of neuropathic origin, pain of ischemic origin or pain developed from various other chronic and progressive ailments. These degenerative changes have also been found to bring about a huge ordeal of discomfort and pain in the patients (Blyth, 2017). This chronic pain has been found to add to the health burden in elderlies as well, adding to the restriction of the activities of daily living. There has also been a direct linkage observed in elderlies suffering from chronic pain to have cognitive disturbances and adding to the underlying risk factors in these population groups. There are multiple factors that might lead to an increase in pain and pain sensitivity in the elderlies. The primary onset can be defined as the physiological changes in the elderlies. These changes are brought about by a decreased release in neurotransmitters such as GABA, serotonin, noradrenaline and so on (Liao, 2018). Due to a deficiency in production of the same, there is a decrease competence of peripheral nociceptive neurons observed. This mechanism brings about an increased pain threshold and reduces the overall endogenous analgesic response. These actions cumulatively result in paradoxical increase in pain, leading to hampered activity. Another pathophysiological factor can be ascertained as homeostenosis process related with aging (Bolduc, 2019). This process leads to a loss of homeostatic reserve in various body organs systems functioning. Thus, leading to increase decline in liver and renal functioning, decreased muscle frailty causing falls, decreased appetite, depression, delirium and an overall behavioural display of irritability. This chronic pain can bring about an overall increased reported incidence of adverse outcomes. These adverse outcomes can be observed in the form of functional impairments, fall, depression and disturbance in overall living pattern of the patient. Chronic pain management in elderlies can be a challenging task, making it more difficult to manage and evaluate their condition. There is also an added impairment observed in elderlies, which can lead to misleading reporting of the pain experienced by them.

Assessment and Evaluation

Through the use of extensive assessment tools, the chronic pain in elderlies can be evaluated and managed efficiently. For enabling care for the patient in the given case scenario a holistic assessment should be carried out for the patient. There are multiple factors that should be assessed as follow:

  • Pain evaluation and assessment- A standard review of the patient history should be taken. The patient should be evaluated from the point of view of any associated risk factor. Taking the history of the patient is also very crucial in the process (Malara, 2016). This can be inclusive of personal history, medication history, functional status and so on. Post-operative pain assessment can be carried out by both self-reported methods used by the patient and as observed by the healthcare professional engaged in patient care. Visual analog scale can be used to assess the patient for pain, by defining it as per numeric score depicting the intensity experienced by the patient. Observation can also be made on the basis of noting for the non-verbal signs of patients expressed through discomfort noted on facial expressions (Karcioglu, 2018). The assessment of dynamic pain in the patient should also be noted, which is usually observed during mild movements made by the patient.
  • Risk of fall assessment and evaluation- This step of assessment can include assessing for the impaired physical mobility of the patient. Her reduced muscle strength and altered sensory reception should also be closely monitored. The use of assistive aids for the patient should also be assessed to prevent further complications like risk of fall (Yang, 2017). Behavioural display like confusion in patients should be closely monitored as it will enable in providing care to the patient. Lack of ability to assess for the patient’s awareness about her surroundings can hamper with the patient care as she will not be able to comply with the treatment intervention.
  • Fluid monitoring- This is a crucial step in assessment and evaluation of the patient. Fluid input and output is vital to be monitored to note for any homeostatic abnormalities in the patient. It can be closely observed with the help of monitoring for vitals such as blood pressure, urine input and output etc. Due to underlying inability of the patient to take in fluids post-surgery, they might require fluid replacement therapy to compensate for the loss (Zhang, 2018). Blood pressure readings can also directly reflect any abnormality in the urine output of the patients. In elderlies, there is an issue of urinary incontinence observed. With the help of noting for urine output on an hourly basis, abnormal and warning signs can be dully noted for.
  • Vital and lab results monitoring- Vital monitoring can be defined as the most apt method of detecting any development of abnormal signs and symptoms. The patient in the case study is aged and is having multiple comorbidities. The underlying risks in elderlies post-operatively are comparatively greater in elderlies than in their young counterparts. Monitoring can be done by the means of noting for parameters such as blood pressure, heart rate, respiratory rate, oxygen saturation and so on (Fahim, 2020). The patient is generally provided heavy dosage of anaesthesia while managing their care with surgical intervention. The patients are observed to have a respiratory depression due to the effect of anaesthesia administered to the patient. By noting the above-mentioned parameters, the patient can be detected for any probable signs of respiratory depression (Gupta, 2018). The lab findings also play a vital role in the managing patient care. They can also severe as an excellent assessment tool for noting the development of any underlying risk factor for the patient. The patient is also suffering from diabetes, so noting for blood glucose levels can be quite helpful in preventing any complications from the same. Other blood tests can be carried out to acknowledge any infection developed in the patient, post-surgical intervention.
  • Assessing for surgical wound- The skin of the older individual is quite fragile and is thus, vulnerable to develop any infection. The wound or surgical site inspection should be assessed by evaluating the color of the skin at the site. It can also be carried out by noting the skin temperature, inspecting it for pus formation, inspecting the wound healing by analysing the margins of the surgical site and so on (Gaur, 2020). With the delayed healing process observed in older population, surgical wound should be inspected for any underlying risk of development of infection for early detection and early prevention.
  • Nutritional assessment- It should be taken into due consideration, especially dealing with older people. The patient is the given case study is a post-operative case. She must be having a restricted diet for now. However, the patient is to be assessed from the point of view of preventing complications such as malnutrition (Abd, 2017). Proper nutritional assessment can also be calculated from the patient personal history and the medical charts.
  • DVT risk assessment- The surgery patient underwent is a complicated one, especially given the age of the patient. The recovery phase might require a lot of bed rest and thus, a restricted movement of the lower limbs. This can also be due to acute pain from surgery. With reduced movement there will be a hampered blood circulation in the body, leading to the complication of the patient developing deep vein thrombosis (Suh, 2017). The patient is also having a history of conditions such as diabetes and hypertension, which are found to be closely associated with impeded blood circulation in the patient. The assessment for development of deep vein thrombosis in patient should also be done from the point of view of evaluating the patient for any underlying cardiac risk factor.

Treatment and Management

Treatment and management of this patient mainly depends on the short-term and long-term goals defined. The short-term goals can be defined as follow:

  • Pain management
  • Preventing bed side complications.
  • Nutritional management
  • Promoting cognitive functioning
  • Promoting the overall health status

The long-term goals can be defined in the case as mentioned-below:

  • Preventing the secondary complications such as infection, bed sores formation, DVT formation etc.
  • Promoting an independent status of functioning.
  • Promoting emotional and mental care for the patient.
  • Family education.
  • Discharge planning
  • Follow-ups with the patient on regular basis.

Short-Term Goals

  • Pain management- The patient can be managed for pain with the help of both pharmacological as well as non-pharmacological treatment modalities. Pharmacological medications can include medicinal drugs such as corticosteroids which are considered as an optimal choice of treatment for the patient. The use of opioid drugs is also very common in managing care for the elderly patients (Zis, 2017). The non-pharmacological methods can include the use of TENS (Trans Electric Nerve Stimulation) (Silva, 2017). This modality is very efficient in promoting pain relief in the patient. The patient can also be provided with ice pack on the surgical site to promote pain relief, especially in acute phase of healing process (Leegwater, 2017). The patient should however, be closely monitored for any discomfort.
  • Preventing bed side complications- These can be inclusive of preventing respiratory depression, preventing any underlying infection and so on. The respiratory depression can be averted by making the patient do breathing exercises. The role of respiratory therapist can be very vital in this given case scenario, as they can help in maintain bronchial hygiene of the patient (Hah, 2017). The therapist can also help in positioning the patient in positions that can ease the pain and promote better ventilation. There is a greater chance of increased mucus production post-surgery in patients. Respiratory techniques can help in lowering the underlying infection chance from inefficient mucus excretion.
  • Promoting nutrition- This can be carried out with the help of dietician. The value of maintaining nutrition is very vital for promoting speedy recovery in the patient. With a good intake of nutritional support, the patient can also be prevented from developing any infection and can have a better immunity for getting recovered. Nutritional support is also important to give, to enhance a good fluid balance in the body (Rattray, 2019).
  • Promoting cognitive functioning- Balance and coordination are very important to promote, so as to prevent the risk of fall in elderly patients. The nurses can work in collaboration with the physical therapist to help the patient with early ambulation (Prabhakar, 2016). Early ambulation will be helpful in promoting confidence in the patient and will also help in enabling a better circulation. The physical therapist can guide the patient on do’s and don’ts and can help in posture correction for them. Early ambulation will also help in pain reduction and also reduce the chances of development of risk factors such as bed sores, formation of vein thrombosis etc.

Long-Term Goals

  • Preventing secondary complications- The patient can be provided with compression sticking to wear while ambulating (Venkataraman, 2019). This is helpful in reducing the risk of deep vein thrombosis development in the patient. The patient should be encouraged for ambulatory life style to enable healthy promotion of blood circulation in the body. This will also help in preventing the chances of infection growth in the patient.
  • Promoting an independent state of functioning- This should be done to promote mental health of the patient. The patients who are elder might feel depressed due to their physical inability and limitations. It is therefore, imperative that mental and physical health should be enabled alongside (Stout, 2019). Patient should be encouraged and motivated for developing an independent way of living and the rehabilitation process should be based on the same.
  • Family education- The patient in the given case study is managed by her daughter. The daughter can work in close coordination with the physical therapist, to promote ambulatory life style for the patient. The family can be educated about the impact of illness on the patient and can be provided with the contacts of support groups that can help in smooth facilitation of delivery of health services to the patients (Madhanraj, 2019). Family can also be educated on the role of emotional comfort along with the physical presence, in attaining improved healthcare outcomes for the patient.
  • Discharge planning- It should be carried out by keeping in mind the physical, emotional as well as environmental limitations of the patient. The residential environment of the patient should be in sync with the preventive measures to undermine the associated risk factors. This can include installation of railings and support bars for the patient to grab on (Wang, 2017). The use of best possible assistive device should also be calibrated for the patient, to help her in promoting her independent status of living.
  • Follow-ups- The nurses can work in close coordination with the general practioners and surgeons aligned in patient care. These regular follow-ups will help the nurse in keeping a close tab on the patient’s progress and planning the interventions, best suitable to attain improved and positive healthcare outcomes from the patient’s recovery process (Hari, 2017).

Conclusion on Post-Op Case of Hip Replacement

Managing a post-operative case can be quite challenging and involves the role of multidisciplinary approach for handling patient care. The challenge multiplies by several folds when the patient is of aged population. However, with a comprehensive and detailed assessment, a well-crafted intervention care plan can be devised, by the means of patient-centred approach model of care. This will be helpful in getting positive healthcare outcomes post-implementation of these strategic interventions’ management for patient care.

References for Post-Op Case of Hip Replacement

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Blyth, F. M., & Noguchi, N. (2017). Chronic musculoskeletal pain and its impact on older people. Best Practice & Research Clinical Rheumatology31(2), 160-168. DOI 10.1016/j.berh.2017.10.004

Bolduc, J. A., Collins, J. A., & Loeser, R. F. (2019). Reactive oxygen species, aging and articular cartilage homeostasis. Free Radical Biology and Medicine132, 73-82. DOI 10.1016/j.freeradbiomed.2018.08.038

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Fahim, M., Visser, R. A., Dijksman, L. M., Biesma, D. H., Noordzij, P. G., & Smits, A. B. (2020). Routine postoperative intensive care unit admission after colorectal cancer surgery for the elderly patient reduces postoperative morbidity and mortality. Colorectal Disease22(4), 408-415.DOI 10.1111/codi.14902

Gaur, A., Jain, M. P., & Joshi, V. (2020). Cemented modular bipolar in unstable femur intertrochanteric fracture in osteoporotic elderly patients-its functional outcomes. International Journal of Orthopaedics6(1), 1250-1254. DOI 10.22271/ortho.2020.v6.i1q.1989

Gupta, K., Prasad, A., Nagappa, M., Wong, J., Abrahamyan, L., & Chung, F. F. (2018). Risk factors for opioid-induced respiratory depression and failure to rescue: A review. Current Opinion in Anaesthesiology31(1), 110-119. DOI 10.1097/ACO.0000000000000541

Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesthesia and Analgesia125(5), 1733. DOI 10.1213%2FANE.0000000000002458

Hari Prasad, S., Patil, S. N., Sarath Chandra, P., & Cecil Fernando, A. (2017). Functional outcome of unstable intertrochanteric femur fracture in elderly osteoporotic patients treated by primary cemented bipolar hemiarthroplasty versus internal fixation with proximal femoral nailing. International Journal of Orthopaedics Sciences3, 319-23. DOI 10.22271/ortho.2017.v3.i4e.43

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Madhanraj, K., Sharma, U., Kaur, S., Tewari, M. K., & Singh, A. (2019). Impact of self-instruction manual-based training of family caregivers of neurosurgery patients on their knowledge and care practices–A randomized controlled trial. Journal of Family Medicine and Primary Care8(1), 209. DOI 10.4103%2Fjfmpc.jfmpc_287_18

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Rattray, M., Roberts, S., Desbrow, B., Wullschleger, M., Robertson, T., Hickman, I., & Marshall, A. P. (2019). A qualitative exploration of factors influencing medical staffs’ decision-making around nutrition prescription after colorectal surgery. BMC Health Services Research19(1), 178. DOI 10.1186/s12913-019-4011-7

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Stout, N. L., Sleight, A., Pfeiffer, D., Galantino, M. L., & deSouza, B. (2019). Promoting assessment and management of function through navigation: opportunities to bridge oncology and rehabilitation systems of care. Supportive Care in Cancer27(12), 4497-4505. DOI 10.1007/s00520-019-04741-0

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 Wang, A. Q. L., Ng, B. H. P., Cheung, L. P. C., & Chin, R. P. H. (2017). Factors affecting mortality and hospital admissions after hip surgery among elderly patients with hip fracture in Hong Kong–Review of a three-year follow-up. Hong Kong Journal of Occupational Therapy30, 6-13.DOI 10.1016/j.hkjot.2017.10.004

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Zis, P., Daskalaki, A., Bountouni, I., Sykioti, P., Varrassi, G., & Paladini, A. (2017). Depression and chronic pain in the elderly: Links and management challenges. Clinical Interventions in Aging12, 709. DOI 10.2147%2FCIA.S113576

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